By Zul Merali
Founding Director,
Brain and Mind Institute,
Aga Khan University
and
Olivera Nesic-Taylor
Senior Science Advisor,
Brain and Mind Institute,
Aga Khan University
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Reading this report reminds us of a quote from Wayne Gretzky, one of the world’s greatest hockey players: “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.” This report is great because it points to what the global challenge is expected to be and what issues will need global attention, particularly for low- and middle-income countries (LMICs).
The World Health Organization (WHO) states that two-thirds of the world’s population over 60 years of age will live in LMICs by the year 2050 (Ageing and Health, who.int). Not surprisingly, many international fora have recognized the significance of that demographic shift. The United Nations (UN) General Assembly declared 2021–2030 the “UN Decade of Healthy Ageing.” However, this recognition of the need to better understand and address the complex problems of aging populations has not yet resulted in globally adopted initiatives that would effectively address aging inequities. This is especially true in LMICs. We applaud the authors of Achieving Equitable Healthy Aging in Low- and Middle-Income Countries: The Aging Readiness & Competitiveness Report 4.0 for informing the readership about aging inequities in LMICs and for advocating a global call to action. The cost of inaction threatens to be dire not only for LMICs but also globally. As the report eloquently elaborates, aging inequities “manifest in unfair differences among older adults related to gender, race, ethnicity, place of residence (rural and urban) and socio-economic status.” This report provides an overview of (a) the situation regarding aging inequities in LMICs and (b) specific challenges in tackling aging inequities in LMICs. It is an up-to-date source of information on current and projected aging trends and on demographic, economic, social, and health characteristics of older populations. It presents insightful conclusions and specific examples of lived experiences across the globe. Eminent authors and contributors have provided the necessary expertise and ensured the highest quality of data presentations, thoughtful analyses, and well-supported propositions.
We have read this report with great interest, given that the Aga Khan University (AKU) serves many LMICs, and its Brain and Mind Institute’s (BMI) mission is “Healthy Brain, Healthy World.” Indeed, the BMI focuses on mental and brain health. One of the BMI hubs is in Kenya (serving East Africa), which shares a unique set of aging-related challenges with other African countries, including its exceptionally young population and lack of aging-related research/data collection.
The World Bank Africa poverty report (Poverty in a Rising Africa) shows that 7 out of the 10 countries with the greatest inequality are in Africa. This economic disparity contributes substantially to aging inequities. We specifically direct readers’ attention to a thorough and insightful description of informal economies, gaps between urban and rural settings, and gender disparities as key factors underlying aging inequities. Clearly, examples of described inequities can be found in all countries, more so in LMICs, but especially in sub-Saharan countries. As a result, older adults in sub-Saharan Africa have shorter life expectancies, suffer higher disability and disease, and often endure severe stigmatization.
Another unique aspect of aging in Africa is that the current sub-Saharan population is remarkably young and is projected to remain so over the next few decades. Given the numerous needs of Africa’s children and youth, it is not surprising that issues of the older population receive limited attention. In sum, the elderly are not yet a health policy priority in Africa.
We commend the authors of this report not only for underscoring current challenges and the need for improving resources and services for aging populations in LMICs but also for offering examples of initiatives that can ensure achievable equitable healthy aging in LMICs. This report describes several inspiring programs with a measurable societal impact, such as the National Health Extension Programs in Ethiopia and the Kaundu Community-Based Health Insurance Program in Malawi, both aiming to mitigate rural–urban inequities.
The ethos of BMI resonates with and wholeheartedly supports the key messages in this report. This is especially true regarding the narrative in section IV, titled “Call to Action,” which concludes that “immediate action is needed to conduct more robust data collection (in LMICs),” since the scarcity of aging-related research in LMICs significantly impairs the creation of interventions that can alleviate aging inequities. Consistent with that, the BMI is in the process of developing a hub for healthy brain aging in Nairobi, Kenya, focused on (a) investigating and addressing biopsychosocial determinants of dementia, (b) aging inequities, and (c) building brain health resilience in East Africa and South and Central Asia. This hub will strive to build the much-needed knowledge base, expertise, and research capacity on aging in East Africa.
Despite extraordinary challenges that the older population in African countries face today or in the future, we would be remiss not to mention opportunities in Africa and lessons we can all learn by better understanding aging in African populations. After all, Homo sapiens walked out of the African Rift Valley to populate the world, evolutionarily speaking. Much value and promise are involved in understanding the roots of human conditions.
The explosive growth in the proportion of young people in sub-Sharan Africa presents a unique opportunity to detect and change trajectories early in the pipeline of the aging population. As the report stated, “Supporting today’s younger generation empowers tomorrow’s older populations.” We would like to add that that support must also include the care for youth mental health as a prerequisite for healthy and equitable aging. Furthermore, we propose that mental health of the older population also needs to be discussed in light of aging inequities and thus should be included in upcoming AARP reports.
There are important lessons to learn through ethnographic and anthropologic studies and better understanding of aging in Africa. Families in Africa are a key care system in which older people are embedded and supported (Reference Keating 2011), nowhere more so than in sub-Saharan Africa. A large body of evidence offers strong support for the importance of good social connections. That is, “living with others, weekly community group engagement, interacting weekly with family and friends, and never feeling lonely” (Associations Between Social Connections and Cognition: A Global Collaborative Individual Participant Data Meta-Analysis, PubMed, nih.gov) are all associated with healthier aging.
Given the absence of similarly well-written compendia analyzing aging inequities in LMICs, and because of its scientific rigor, we highly recommend this report to researchers, educators, policy makers, and the general public interested in a better understanding of aging inequities not only in LMICs, but also in middle- to high-income countries.